Provider Demographics
NPI:1154843746
Name:EVANGELISTA, MICHELE ANN (MASSAGE THERAPIST)
Entity Type:Individual
Prefix:MRS
First Name:MICHELE
Middle Name:ANN
Last Name:EVANGELISTA
Suffix:
Gender:F
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 631552
Mailing Address - Street 2:
Mailing Address - City:LANAI CITY
Mailing Address - State:HI
Mailing Address - Zip Code:96763-1552
Mailing Address - Country:US
Mailing Address - Phone:808-565-8009
Mailing Address - Fax:
Practice Address - Street 1:1270 OLAPA STREET
Practice Address - Street 2:
Practice Address - City:LANAI CITY
Practice Address - State:HI
Practice Address - Zip Code:96763
Practice Address - Country:US
Practice Address - Phone:808-565-8009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-14
Last Update Date:2017-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMAT-14505225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist